Provider Demographics
NPI:1881853026
Name:RISTAU, SUSAN ALICE (LPC)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ALICE
Last Name:RISTAU
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3288 SUTCLIFFE RDG NW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30064-1737
Mailing Address - Country:US
Mailing Address - Phone:770-235-3837
Mailing Address - Fax:678-797-1000
Practice Address - Street 1:1000 CHASTAIN RD NW
Practice Address - Street 2:KENNESAW HALL, SUITE 2419
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-5588
Practice Address - Country:US
Practice Address - Phone:770-423-6746
Practice Address - Fax:678-797-1000
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2483101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional